Assessment of Psychosocial Contributions to Disability

Abstract

Disability has traditionally been defined in terms of a largely biomedical model, where an individual’s limitations were seen as being the product of objectively verifiable physical problems. More recently though, disability has been redefined in terms of functionality within a social context. Thus, disability is best understood as a biopsychosocial phenomenon that combines biological, psychological, and social elements. Biopsychosocial assessment has inherent difficulties. Patients may lack insight into their psychological status and thus be unable to answer certain questions. Further, even if patients do have adequate insight, they may be motivated somehow to bias their reports of information. One method to overcome these challenges is the use of standardized psychometric measures that include validity assessment. Disability has traditionally been defined in biomedical terms and closely associated with objective physical impairment (Pledger, Am Psychol 58:279–284, 2003). More recent conceptualizations though hold that a comprehensive evaluation of disability requires not only the assessment of objective physical impairment but also an assessment of the psychosocial context in which the disability occurs. This conceptualization changed due to findings such as Ormel’s global study of 26,000 patients in 14 countries, which examined the origins of disability. The study determined that psychological factors were more predictive of physical disability than was disease severity (Ormel et al., JAMA 272:1741–1748, 1994).

Even when medical disorders are not present, psychological disorders can be disabling. According to the World Health Organization, mental health disorders are the most disabling of all conditions, accounting for 31% of the world’s disability (Mnookin, World Bank Group, & World Health Organization, Out of the shadows: Making mental health a global development priority. Geneva: World Health Organization, 2016; World Health Organization, Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000–2015. Retrieved from Geneva: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html, 2016). Among mental health disorders, depression is the most disabling single condition in the world, accounting for 7.5% of the world’s disability, while anxiety accounts for an additional 3.4% (World Health Organization, Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000–2015. Retrieved from Geneva: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html, 2016).

Among SSDI recipients in the United States, more than half have a disability involving psychological or subjective symptoms (especially pain, as pain disorders are a psychological condition), with 33% of SSDI recipients in 2010 having psychological disorders (up from 22% in 1986) and 28% suffering from painful musculoskeletal disorders (Congressional Budget Office, Policy Options for the Social Security Disability Insurance Program. Retrieved from http://www.cbo.gov/sites/default/files/cbofiles/attachments/43421-DisabilityInsurance_screen.pdf, 2012). These patients tend to gain disability status earlier in life, and stay on SSDI longer, because psychological and musculoskeletal conditions are less likely to be fatal.

Some psychosocial risk factors for disability such as socioeconomic status are objective in nature. In contrast, other psychosocial risk factors, such as depression, are determined to a large extent by the report of subjective states. To assess these subjective states, standardized psychological tests can play a valuable role. The defining characteristics of standardized psychological tests are discussed, as are their uses. Commonly used psychological tests are reviewed. Practical questions are also addressed, such as when to administer psychological tests, what psychosocial risk factors need to be assessed, what tests to use, methods of quantifying the level of psychosocial risk, and the detection of faking.

Appendix: Psychometric Assessment Tools

The tests listed below are for informational purposes only, and this is not an exhaustive list. The final decision about which tests to use must be left to the evaluator. Within each section, tests are listed in alphabetical order.

Assessment task

Test

Notesa

Description

Brief assessments of emotion

These tests are useful when the assessment of a patient’s emotional status is desired

Hamilton Depression Inventory: Brief measure of depression, widely used in research. Assesses a broad range of cognitive, affective, and physical depressive symptoms. Uses community norms. 23 items, 1 scale, fifth grade reading level, no validity measures, 5 min. A variation of this is the Hamilton Rating Scale, which is a 17 or 21 item measure filled out by the professional

Oswestry Low Back Pain Disability Questionnaire: Commonly used measure of functioning in research studies is known to be sensitive to assess change. Original version has been shown to be an effective research outcome measure, multiple modified versions, and no norms. 20 Items, 1 scale, no validity measures, 4–5 min

PROMIS

PDQ

S J N

J G

Patient-Reported Outcomes Measurement Information System: A set of measures developed by US Department of Health and Human Services that assesses physical, mental, and social health in adults and children across all conditions

Roland and Morris Disability Questionnaire: Commonly used measure of functioning in research studies is known to be able to assess change in functioning. Original version is a frequently used research outcome measure.

Short Form 36 Questionnaire Version 2: Overall assessments of physical and mental health. Function scale is the strongest and it assesses subjective reports of impairment. Has scoring software. Original SF 36 is less well standardized. SF 36-V2 has an improved administration format, norms, and standardized scores. 36 items, 8 scales, no validity measures, 6–8 min

Pain Visual Analog Scale: Sensitive measure of pain used extensively in research. Unstandardized test, with unknown number of variations. No agreement on graphic format of test (e.g., length of line; does the line have numbers on it), location (e.g., rating whole body vs. one body part) or time (e.g., right now vs. typical). No norms. <1 min

Computerized Assessment of Response Bias: Used to assess whether an individual is falsifying symptoms of memory impairment. No norms

Hare

S J B G N

Hare Psychopathy Checklist – Revised: The assessment can be used to help assess the degree to which an individual exhibits severe antisocial traits, in the form of a prototypical violent psychopath. May be useful if assessing patients who are making threats

SIMS

S J B G N

Structured Inventory of Malingered Symptomatology: Used for both malingered psychopathology and neuropsychological symptoms

TOMM

S J B G N

Test of Memory Malingering: Used to assess whether an individual is falsifying symptoms of memory impairment. No norms

Word Memory Test: Used to assess whether an individual is falsifying symptoms of verbal memory impairment. No norms

Assessment of cognitive ability

These tests are measures of intelligence, memory, and cognitive processing ability

GAMA

S J B G N

Global Assessment of Mental Ability: Culture-free measure of general intellectual ability. Based on the scores on four subtest scales: matching, analogies, sequences, and construction. Community norms. 25 min timed test

RBANS

S J B G N

Repeatable Battery for the Assessment of Neuropsychological Status: Measures neuropsychological status and cognitive decline in individuals who have experienced stroke, head injury, dementia, or neurological injury or disease. Community norms. Less than 30 min

WASI

S J B G N

Wechsler Abbreviated Scale of Intelligence: An abbreviated measurement of adult intelligence in short and very short forms. 15 min for 2 subtests IQ. 30 min for 4 subtest IQ

American Educational Research Association, American Psychological Association, National Council on Measurement in Education, Joint Committee on Standards for Educational and Psychological Testing (U.S.). (1999). Standards for educational and psychological testing. Washington, DC: American Educational Research Association.Google Scholar

Mnookin, S., & World Bank Group, World Health Organization. (2016). Out of the shadows: Making mental health a global development priority. Geneva, Switzerland: World Health Organization.Google Scholar

U.S. Department of Education, Office of Special Education and Rehabilitative Services National Institute on Disability and Rehabilitation Research. (2009). Long range plan: 1999–2003. Washington, DC: U.S. Department of Education.Google Scholar